Healthcare Provider Details

I. General information

NPI: 1235146846
Provider Name (Legal Business Name): GREGORY WAYNE MALLARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W JACKSON ST
PIGGOTT AR
72454-1538
US

IV. Provider business mailing address

140 STONERIDGE DR S STE 100
RUCKERSVILLE VA
22968-3096
US

V. Phone/Fax

Practice location:
  • Phone: 870-598-2236
  • Fax: 870-598-3080
Mailing address:
  • Phone: 434-654-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE2399
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101265974
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: